Improving care for patients with non-cardiac chest pain: Description of psychological distress and costs, and evaluation of an Internet-delivered intervention

Mourad, Ghassan

Linköping University, Department of Social and Welfare Studies, Division of Health, Activity and Care. Linköping University, Faculty of Medicine and Health Sciences.

2015 (English)Doctoral thesis, comprehensive summary (Other academic)

Abstract [en]

Introduction: More than half of all patients seeking care for chest pain do not have a cardiac cause for this pain. Despite recurrent episodes of chest pain, many patients are discharged without a clear explanation of the cause for their pain. A lack of explanation may result in a misinterpretation of the pain as being cardiac-related, causing worry and uncertainty, which in turn leads to substantial use of healthcare resources. Psychological distress has been associated with non-cardiac chest pain (NCCP), but there is limited research regarding the relationship between different psychological factors and their association with healthcare utilization. There is a need for interventions to support patients to manage their chest pain, decrease psychological distress, and reduce healthcare utilization and costs.

Aim: The overall aim of this thesis was to improve care for patients with non-cardiac chest pain by describing related psychological distress, healthcare utilization and societal costs, and by evaluating an Internet-delivered cognitive behavioural intervention.

Designs and methods: This thesis presents results from four quantitative studies. Studies I and II had a longitudinal descriptive and comparative design. The studies used the same initial cohort. Patients were consecutively approached within 2 weeks from the day of discharge from a general hospital in southeast Sweden. In study I, 267 patients participated (131 with NCCP, 66 with acute myocardial infarction (AMI), and 70 with angina pectoris (AP)). Out of these, 199 patients (99 with NCCP, 51 with AMI, 49 with AP) participated in study II. Participants were predominantly male (about 60 %) with a mean age of 67 years. Data was collected on depressive symptoms (Study I), healthcare utilization (Study I, II), and societal costs (Study II). Study III had a cross-sectional explorative and descriptive design. Data was collected consecutively on depressive symptoms, cardiac anxiety and fear of body sensations in 552 patients discharged with diagnoses of NCCP (51 % women, mean age 64 years) from four hospitals in southeast Sweden. Patients were approached within one month from the day of discharge. Study IV was a pilot randomized controlled study including nine men and six women with a median age of 66 years, who were randomly assigned to an intervention (n=7) or control group (n=8). The intervention consisted of a four-session guided Internet-delivered cognitive behavioural therapy (CBT) program containing psychoeducation, exposure to physical activity, and relaxation. The control group received usual care. Data was collected on chest pain frequency, cardiac anxiety, fear of body sensations, and depressive symptoms.

Results: Depressive symptoms were prevalent in 20 % (Study IV) and 25 % (Study I, III) of the patients, and more than half of the patients still experienced depressive symptoms one year later (Study I). There were no significant differences in prevalence and severity of depressive symptoms between patients diagnosed with NCCP, AMI or AP. Living alone and younger age were independently related to more depressive symptoms (Study I). Cardiac anxiety was reported by 42 % of the patients in study III and 67 % of the patients in study IV. Fear of body sensations was reported by 62 % of the patients in study III and 93 % of the patients in study IV. On average, patients with NCCP had 54 contacts with primary care or the outpatient clinic per patient during the two-year study period. This was comparable to the number of contacts among patients with AMI (50 contacts) and AP (65). Patients with NCCP had on average 2.6 hospital admissions during the two years, compared to 3.6 for patients with AMI and 3.9 for patients with AP (Study II). Four out of ten patients reported seeking healthcare at least twice during the last year due to chest pain (Study III). On average, 14 % of patients with NCCP were on sick-leave annually, compared to 18 % for patient with AMI and 25 % for patient with AP. About 11-12 % in each group received a disability pension. The mean annual societal costs for patients with NCCP, AMI and AP were €10,068, €15,989 and €14,737 (Study II). Depressive symptoms (Study I, III), cardiac anxiety (Study III) and fear of body sensations (Study III) were related to healthcare utilization. Cardiac anxiety was the only variable independently associated with healthcare utilization (Study III). In the intervention study (Study IV), almost all patients in both the intervention and control groups improved with regard to chest pain frequency, cardiac anxiety, fear of body sensations, and depressive symptoms. There was no significant difference between the groups. The intervention was perceived as feasible and easy to manage, with comprehensible language, adequate and varied content, and manageable homework assignments.

Conclusions: Patients with NCCP experienced recurrent and persistent chest pain and psychological distress in terms of depressive symptoms, cardiac anxiety and fear of body sensations. The prevalence and severity of depressive symptoms in patients with NCCP did not differ from patients with AMI and patients with AP. NCCP was significantly associated with healthcare utilization and patients had similar amount of primary care and outpatient clinic contacts as patients with AMI. The estimated cumulative annual national societal cost for patients with NCCP was more than double that of patients with AMI and patients with AP, due to a larger number of patients with NCCP. Depressive symptoms, cardiac anxiety and fear of body sensations were related to increased healthcare utilization, but cardiac anxiety was the only variable independently associated with healthcare utilization. These findings imply that screening and treatment of psychological distress should be considered for implementation in the care of patients with NCCP. By reducing cardiac anxiety, patients may be better prepared to handle chest pain. A short guided Internet-delivered CBT program seems to be feasible. In the pilot study, patients improved with regard to chest pain frequency, cardiac anxiety, fear of body sensations, and depressive symptoms, but this did not differ from the patients in the control group who received usual care. Larger studies with longer follow-up are needed to evaluate both the short and long- term effects of this intervention.

Abstract [en]

OBJECTIVES: We compared depressive symptoms and healthcare utilization in patients admitted for noncardiac chest pain, acute myocardial infarction, and angina pectoris after hospitalization and at 1-year follow-up. METHODS: One hundred and thirty-one patients with noncardiac chest pain, 66 with acute myocardial infarction, and 70 with angina pectoris completed a depression screening questionnaire and the Montgomery Åsberg Depression Rating Scale. Healthcare utilization data were collected from a population-based, diagnosis-related database. RESULTS: More than 25% of respondents reported depressive symptoms, regardless of diagnosis. At follow-up, 9% had recovered, 19% were still experiencing depressive symptoms, and 13% had developed depressive symptoms. Noncardiac patients with chest pain had similar primary care contacts, but fewer hospital admissions, than patients with an acute myocardial infarction. Patients with angina pectoris and depressive symptoms used the most healthcare services. CONCLUSIONS: Depressive symptoms were common. Patients with noncardiac chest pain used as much primary care as did patients with an acute myocardial infarction. Interventions should focus on identifying and treating depressive symptoms.

Abstract [en]

Background

Non-cardiac chest pain (NCCP) is a common complaint. Our aim was to present a detailed description of the costs of patients with NCCP compared to patients with acute myocardial infarction (AMI) and Angina Pectoris (AP) from a societal perspective.

Methods

Data on healthcare utilization and annual societal costs, including direct healthcare costs and indirect costs due to productivity loss, were collected from different databases. The participants consisted of 199 patients from a general hospital in Sweden (99 with NCCP, 51 with AMI, 49 with AP), mean age of 67 years, 59% men.

Results

NCCP, AMI, and AP patients had on average 54, 50 and 65 primary care contacts and 3, 4, and 4 hospital admissions during a period of 2 years. Length of hospital stay was 6, 11 and 11 days. On average, 14%, 18%, and 25% of NCCP, AMI and AP patients were on sick-leave annually, and about 12% in each group received a disability pension. The mean annual societal costs of NCCP, AMI and AP patients were €10,068, €15,989 and €14,737.

Conclusions

Although the annual societal cost of NCCP patients was lower than in AMI and AP patients, the cost was still considerable (€10,068). Taken into account the high prevalence of NCCP, the cumulative annual national cost of these patients could be more than the double of AMI and AP if all patients incurred the same costs as in this study. Targeted interventions are important in order to support patients with NCCP and minimize healthcare utilization and costs.

Open this publication in new window or tab >>Depressive Symptoms, Cardiac Anxiety, and Fear of Body Sensations in Patients with Non-Cardiac Chest Pain, and Their Relation to Healthcare-Seeking Behavior: A Cross-Sectional Study

Mourad, Ghassan

Linköping University, Department of Social and Welfare Studies, Division of Nursing Science. Linköping University, Faculty of Medicine and Health Sciences.

Abstract [en]

BACKGROUND: Patients with non-cardiac chest pain (NCCP) suffer from recurrent chest pain and make substantial use of healthcare resources.

OBJECTIVE: To explore the prevalence of depressive symptoms, cardiac anxiety, and fear of body sensations in patients discharged with a NCCP diagnosis; and to describe how depressive symptoms, cardiac anxiety, and fear of body sensations are related to each other and to healthcare-seeking behavior.

METHODS: Cross-sectional design. Data were collected between late October 2013 and early January 2014 in 552 patients with NCCP from four hospitals in southeast Sweden, using the Patient Health Questionnaire-9, Cardiac Anxiety Questionnaire, and Body Sensations Questionnaire.

CONCLUSION: Patients with NCCP and many healthcare consultations had high levels of depressive symptoms and cardiac anxiety, and moderate levels of fear of body sensations. Cardiac anxiety had the strongest relationship with healthcare-seeking behavior and may therefore be an important target for intervention to alleviate suffering and to reduce healthcare use and costs.

Jaarsma, Tiny

Linköping University, Department of Social and Welfare Studies, Division of Health, Activity and Care. Linköping University, Faculty of Medicine and Health Sciences.

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2015 (English)Manuscript (preprint) (Other academic)

Abstract [en]

Background: Patients with recurrent episodes of non-cardiac chest pain (NCCP) may suffer from cardiac anxiety and avoidance behavior, leading to increased healthcare utilization. These patients might benefit from help and support to evaluate the perception and management of their chest pain.

Objective: To test the feasibility of a short guided Internet-delivered CBT intervention and the effects on chest pain, cardiac anxiety, fear of body sensations and depressive symptoms in patients with NCCP compared to usual care.

Methods: A pilot randomized controlled study was conducted. Fifteen patients, nine men and six women with a median age of 66 years (range 22-76), were randomly assigned to either intervention (n=7) or control (n=8) group. Patients had recurrent episodes of non-cardiac chest pain and suffered from cardiac anxiety and/or fear of body sensations. The intervention consisted of a four-session guided Internet-delivered CBT program containing psychoeducation, physical activity, and relaxation. The control group received usual care. All patients completed a web-based questionnaire on socio-demographic variables, chest pain frequency, cardiac anxiety, fear of body sensations, and depressive symptoms.

Results: Five out of the seven patients in the intervention group completed all sessions as planned and two joined only parts of the program. The program was perceived as userfriendly with understandable language, adequate and varied content, and manageable homework assignments. The patients were engaged in the program for about 60 minutes per day and about 22 minutes’ therapist time was required to guide, support and give feedback to each patient through the program. Participating in the program, particularly being guided and supported, empowered and motivated many of the patients to be active and complete the program. In general, patients in both intervention and control groups improved with regard to chest pain frequency, cardiac anxiety, fear of body sensations, and depressive symptoms, but there were no significant differences between the groups.

Conclusions: A short guided Internet-delivered CBT program was feasible. Patients in both intervention and control groups improved with regard to chest pain frequency, cardiac anxiety, fear of body sensations, and depressive symptoms, but no significant differences were found between the groups. Patients should be followed-up for longer periods to measure the long-term effects of the intervention.